Relapse following emergency treatment for acute asthma: Can it be predicted or prevented?

doi:10.1016/0895-4356(93)90139-R

Journal of Clinical Epidemiology

Volume 46, Issue 12, December 1993, Pages 1395-1402

https://doi.org/10.1016/0895-4356(93)90139-R Get rights and content

Abstract

We prospectively followed 314 children discharged from a children's hospital emergency department (ED) following an asthma attack, to identify risk, factors for relapse, i.e. a second ED visit for asthma within the next 10 days. Parents were surveyed concerning their child's past medical history, drugs received prior to the index visit, triggering factors, physician availability, parental anxiety, and sociodemographic variables. Data on severity of the attack, emergency treatment, response to treatment and drugs prescribed on discharge were extracted from the medical record. Ninety-six of the 314 children (31%) relapsed, most (68%) within 24 hours. Using multiple logistic regression, a predictive model was developed on 211 patients (“test sample”). The best model contained two variables: (1) the number of ED visits for acute asthma in the previous year (odds ratio [OR] = 2.4 for 4 or more vs fewer visits, 95% CI = 1.3–4.4) and (2) the intake of an oral short-acting theophylline preparation during the course of the acute treatment (OR = 0.4, 95% CI = 0.2-0.7). The sensitivity, specificity and positive predictive values of this model for predicting relapse were 73, 53, and 40%, respectively. When applied to a second randomly selected “validation sample” of 103 children, sensitivity was 73%, specificity 50%, and PPV 41%, thus indicating the stability of the model. The model identifies the number of ED visits in the previous year as an important risk factor for relapse. It also suggests that oral short-acting theophylline may still have a role in the treatment of patients in whom the contribution of inflammation to airway obstruction is minimal.

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Emergency department (ED) visits and hospitalization are common, costly and the greatest disease burden to children with asthma. Admission rates for asthma vary substantially by site and ED provider. Disease heterogeneity and ED provider uncertainty surrounding likelihood of successful discharge contribute to potentially avoidable hospitalizations. New approaches to improve ED disposition decision-making could improve patient care and reduce waste associated with unnecessary hospitalizations. Several asthma severity scores and asthma prediction models have been evaluated for their ability to predict ED disposition for childhood asthma. Our objective is to review prior studies that modeled predictors of disposition outcomes for children treated in ED settings for acute asthma exacerbations.
Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization
2017, Annals of Emergency Medicine
Citation Excerpt :
ED visits for asthma after hospitalization are common and may be related to severity of disease. Children of minority race and those with public insurance, history of asthma-related ED visit or hospitalization, and suboptimal asthma control are more likely to visit (and revisit) the ED.12-19 However, many studies describing risks related to ED utilization and reutilization have minimal patient-level data beyond these basic factors, elements that may aid in the discovery of modifiable ways to reduce asthma morbidity.20-23
We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma.
This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit.
A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit.
Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.
Development and Internal Validation of a Pediatric Acute Asthma Prediction Rule for Hospitalization
2015, Journal of Allergy and Clinical Immunology: In Practice
Clinicians have difficulty predicting need for hospitalization of children with acute asthma exacerbations.
The objective of this study was to develop and internally validate a multivariable asthma prediction rule (APR) to inform hospitalization decision making in children aged 5-17 years with acute asthma exacerbations.
Between April 2008 and February 2013 we enrolled a prospective cohort of patients aged 5-17 years with asthma who presented to our pediatric emergency department with acute exacerbations. Predictors for APR modeling included 15 demographic characteristics, asthma chronic control measures, and pulmonary examination findings in participants at the time of triage and before treatment. The primary outcome variable for APR modeling was need for hospitalization (length of stay >24 h for those admitted to hospital or relapse for those discharged). A secondary outcome was the hospitalization decision of the clinical team. We used penalized maximum likelihood multiple logistic regression modeling to examine the adjusted association of each predictor variable with the outcome. Backward step-down variable selection techniques were used to yield reduced-form models.
Data from 928 of 933 participants were used for prediction rule modeling, with median [interquartile range] age 8.8 [6.9, 11.2] years, 61% male, and 59% African-American race. Both full (penalized) and reduced-form models for each outcome calibrated well, with bootstrap-corrected c-indices of 0.74 and 0.73 for need for hospitalization and 0.81 in each case for hospitalization decision.
The APR predicts the need for hospitalization of children with acute asthma exacerbations using predictor variables available at the time of presentation to an emergency department.
Potential predictors of relapse after treatment of asthma exacerbations in children
2014, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Emerman et al12 gave systemic steroids to more than 75% of the patients in their study, and in their 2-week follow-up, they found the rate of revisits to be 10%. In the study by Ducharme et al,13 a few patients were given systemic steroids when sent home. They reported that the rate of revisit was 31% at the end of a 2-week follow-up.
Knowledge of factors that affect relapse will allow close monitoring of patients at risk, resulting in a decreased rate of readmission to the emergency department.
To determine risk factors associated with relapse within 7 days after treatment of asthma exacerbations in children.
This was a multicenter, prospective study of children with asthma attacks. Patients between the ages of 6 months and 17 years who met the criteria between June 2009 and September 2012 were considered.
The study included 1177 patients (775 males [65.8%]) with a mean (SD) age of 70.72 (48.24) months. Of them, 199 (16.9%) had a relapse within 1 week after being discharged from the hospital. Factors independently associated with relapse identified by a logistic regression model for the 1,177 study visits were having taken a short-acting inhaled β₂-agonist within 6 hours before admission (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.728-3.426; P = .001), presence of retraction on physical examination (OR, 1.76; 95% CI, 1.123-2.774; P = .01), no prescription for high-dose inhaled steroids on release (OR, 2.02; 95% CI, 1.370-3.002; P < .001), and not being given a written instructional plan (OR, 1.55; 95% CI, 1.080-2.226; P = .02).
Whereas having taken short-acting β₂-agonists within 6 hours before admission and the presence of retractions on physical examination increased the risk of relapse after treatment of the acute attack, being given high-dose inhaled steroids and a written instructional plan when being sent home reduced the risk.
Risk Factors for Repeat Adverse Asthma Events in Children After Visiting an Emergency Department
2008, Ambulatory Pediatrics
Citation Excerpt :
It is generally accepted that asthma is an ambulatory care–sensitive condition, and appropriate outpatient management results in decreased urgent health care use.22 However, previous studies3–10 conducted under both private and public health care systems showed that outcomes of children attending an ED for asthma were far from ideal. For example, Spurrier and colleagues9 followed children with asthma for 6 months after attending an ED and found that 37% had at least 1 unplanned subsequent visit to the ED.
The aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED).
A prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders.
Of the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15–0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20–0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes.
Our study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.
Asthma attacks in primary care
2006, FMC Formacion Medica Continuada en Atencion Primaria

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^☆: Presented in part at the Ambulatory Pediatric Association, Anaheim, CA, May 1990.

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Original articleRelapse following emergency treatment for acute asthma: Can it be predicted or prevented?☆

Abstract

J Pediatr

J Pediatr

J Pediatr

Am J Med

J Pedistr

Definitions and classifications of chronic bronchitis, asthma, and pulmonary emphysema

Am Rev Respir Dis

Is the prevalence of asthma changing?

Arch Dis Child

Hypothèses sur les changements dans la fréquency de l'asthme

Can Med Assoc J

The changing frequency of childhood asthma

J Asthma

Early prediction of the need for hospitalization in children with acute asthma

Clin Pediatr

Attempting to predict hospital admission in acute asthma

Am J Dis Child

Pediatric predictive index for hospitalization in acute asthma

Ann Emerg Med

An index predicting relapse and need for hospitalisation in patients with acute bronchial asthma

N Engl J Med

Performance of an index predicting the response of patients with acute bronchial asthma to intensive emergency department treatment

N Engl J Med

Inability to predict relapse in acute asthma

N Engl J Med

Original article
Relapse following emergency treatment for acute asthma: Can it be predicted or prevented?☆